Florida Department of Health

Comprehensive Cancer Control Program: Evaluation Report 2017-2018 July 2017 to June 2018

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Comprehensive Cancer Control Program 2017-2018

Annual Progress Evaluation

Florida Statute

Statutory authority is captured in Florida Statutes, Chapter 385.103, regarding chronic disease

prevention and control intervention programs defined by the Florida Department of Health’s (FDOH) role

in preventing chronic disease.1 Florida Statute, Section 1004.435,2 defines the makeup of the Cancer

Control Research and Advisory Council (C-CRAB)3 which functions as the Comprehensive Cancer Control

Program (FCCCP) coalition. The 2015 Florida Cancer Control and Research Plan was created by C-CRAB

executive members and is currently operationalized by statewide stakeholders.

Alignment to the State Strategic Plans

The FDOH conducted a strategic planning process during the summer of 2015 and defined how to

evaluate and update regularly to address new challenges posed by the changing public health environment

in Florida. In conjunction with the agency plan, FDOH and an external group of stakeholders, such as

state and local government agencies, health care providers, employers, community groups, universities

and schools, non-profit organizations, and advocacy groups, provided input to the State Health

Improvement Plan (SHIP) Steering Committee. Objectives developed were directed by the State Health

Assessment and used the Mobilizing for Action through Planning and Partnership process to select

priorities to improve the health of Florida residents. Of the priorities included in these two plans, the

FCCCP workplan seeks to impact and contribute to achieving four objectives: overall cancer mortality,

colorectal cancer screening rates, and human papillomavirus (HPV) vaccination rates for males and

females (see Table 1).

Evaluation Purpose

The purpose of this evaluation is to assess the FCCCP based on administrative processes,

effectiveness, and progress made on cancer control planning and implementation efforts on short,

intermediate, and long-term outcomes associated with the program. The FCCCP, created through a

cooperative agreement with and funded by the Centers for Disease Control and Prevention (CDC),

1Florida Legislator. 2018 Florida Statutes. Primary and Preventive Health Services. Retrieved from www.leg.state.fl.us/statutes/index.cfm?mode=View%20Statutes&SubMenu=1&App_mode=Display_Statute&Search_String=381.005&URL=0300-0399/0381/Sections/0381.005.html on 8-17-2018. 2 Florida Legislator. 2018 Florida Statutes. Cancer Control and Research. Retrieved from www.leg.state.fl.us/STATUTES/index.cfm?App_mode=Display_Statute&Search_String=&URL=1000-1099/1004/Sections/1004.435.html on 8-17-2018. 3 Cancer Control and Research Advisory Council. Retrieved from www.ccrab.org/ accessed 8-17-2018.

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Table 1: FCCCP Alignment Florida State Strategic Plans

Florida Department of Health Strategic Plan Objectives Alignment with Cancer Program Efforts

Objective SHIP4 Agency Strategic

Plan5

Bureau Assigned To

By December 31, 2020, reduce the overall age-adjusted rate of cancer deaths from 160.3 (2012) to 145.0 per 100,000 population.

NA 2.1.3A Director’s Office

By December 31, 2021, increase the percentage of adults ages 50 to 75 who received colorectal screening based on the most recent guidelines from 65.7% (2014) to 80%.

CD1.1.3 NA Tobacco Free Florida

By December 31, 2021, increase the rate of male teens (13–17 years of age) who have completed the first dose of HPV vaccines from 41.0% (2014) to 50%.

IM2.1.2 NA Epidemiology

By December 31, 2021, increase the rate of female teens (13–17 years of age) who have completed the first dose of HPV vaccine from 57.2% (2014) to 70%.

IM2.1.3 NA Epidemiology

employs cancer control efforts through the development and implementation of a strategic and

collaborative approach to implementing data-driven and evidence-based practices to address cancer

disparities, cancer prevention, access to cancer care, and cancer survivorship activities statewide.

This evaluation report captures progress made by the FCCCP to achieve or support goals and

objectives defined by state and regional cancer control planning. The 2015 Florida Cancer Control and

Research Plan (Florida Cancer Plan) provides state level goals and strategies for reducing the overall

cancer burden and is further developed into action plans and implemented of regional collaborative

strategic plans. Regional collaborative partnerships developed a variety of objectives across a range of

general topics including: human papillomavirus (HPV) vaccination, tobacco use reduction, increased

access to cancer care, and support for cancer survivor support services. FCCCP administrative efforts

facilitated more robust implementation efforts through competitive funding announcements and ongoing

technical assistance during execution of evidence-based interventions (EBIs).

The activities assessed in this evaluation report are continuous and ongoing, with a strong

emphasis on process assessment within three CDC-defined focus areas: partnerships, program, and plan.

Key evaluation questions were developed within each focus area to guide quantitative and qualitative data

collection, defined by the logic model within the 2017-2020 FCCCP Evaluation Plan, and highlight the

importance of data driven practices and EBIs (see Table 2).

4 Florida Department of Health Strategic Priority 2.1.3 Reduce cancer incidence and increase cancer survival: http://www.floridahealth.gov/about-the-department-of-health/about-us/state-and-community-health-assessment/ship-process/SHIP-goals-strat-obj.7.pdf?utm_source=flhealth.gov-call-out Accessed 2-9-2016 5 Florida Department of Health. (2017). Florida Department of Health Agency Strategic Plan 2016-2018.

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Table 2: Logic Model Activity Alignment with Key Questions

Logic Model Activity/Outcome

Focus Question

Program Collaboration

Program What methods were used to improve planning coordination between statewide external partnerships and internal stakeholders?

External Partnerships

Partnership How involved are the regional collaborative partners with the direction and progress of collaborative-based efforts and interventions?

External Partnerships

Partnership How has the FCCCP influenced regional activities to reduce cancer risk, partner health system change, use of patient navigators for cancer screening appointment, and community-clinic linkages?

Cancer Data and Surveillance

Plan Have EBIs maintained the fidelity of the regional strategic plans (i.e., delivered as it was intended)?

Cancer Data and Surveillance

Plan How have cancer plan objectives increased regional support for cancer activities?

Cancer Data and Surveillance

Plan How were cancer data used to plan and guide FCCCP efforts statewide?

Policy Changes Program How has cancer prevention activities increased over the past year?

Health Care System Changes

Program How has cancer survivor support increased over the past year?

Provider Changes Program How have cancer disparities decreased over the past year?

Provider Changes and Individual Changes

Program How has cancer screening awareness and education increased over the past year?

Evaluation Action-Based Questions

1. How involved are the regional collaborative partners with the direction and

progress of collaborative-based efforts and interventions?

Objectives and strategies identified in the 2017-2018 regional cancer control collaborative

strategic plans were used to define opportunities for funding and outreach. Three funding

opportunities were selected from the 34 possible EBI objectives identified in the 2017-2018

strategic plans: increasing HPV vaccination within individual health systems and increase access

to cancer screening and cancer survivor support services by improving community-clinical

linkages between partner health systems (see Table 3).

Table 3: Regional Collaborative Strategies by Florida Cancer Plan Theme, 2017-2018

Cancer Plan Theme Completed Ongoing Total

No theme: administrative 6 6 12

Cancer data and surveillance 2 0 2 Cancer prevention: healthy behaviors and cancer screening 3 9 12

Cancer survivorship 2 6 8

Grand Total 13 21 34

Six regional cancer control collaboratives meet quarterly to semiannually during this

reporting period. A total of 224 members were engaged at regional planning meetings to review

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and develop strategies based on the Florida Cancer Plan. Over this period, 499 hours were

generated to support planning efforts, with an additional 226 hours focused on reviewing and

applying cancer disparity data. As of June 2018, 13 of the 34 objectives identified by regional

partners were completed within the reporting period (see Table 3).

2. How has the FCCCP influenced regional activities to reduce cancer risk, partner

health system change, use of patient navigators for cancer screening appointment,

and community-clinic linkages?

Funding opportunities were developed based on 2017-2018 regional objectives. Top

priority efforts in cancer prevention, access to cancer care, and cancer survivorship were

fashioned into funding announcements for stakeholder bidding using recommended best

practices and EBI based on recommendations from the Community Preventive Service Task Force

(CPSTF). CPSTF is an independent, nonfederal panel of public health and prevention experts that

provides evidence-based findings and recommendations about community-based preventive

services, programs, and other interventions. Based on independent review, funding was allocated

to the top bids to support proposal invitations for Partnering Health Systems to increase the use

of EBIs.

The prevention intervention funding proposal focused on HPV vaccination.6,7 The access

to cancer care and survivorship intervention funding proposals focused on community-clinical

linkages. Scoring of proposals favored sites with proven track record of systems change work,

strong administrative support, defined need based on state and regional averages. Evaluators

were directed to score proposals using the following criteria: need, feasibility, replicability, benefit

analysis, and systems change.

In total, 12 contracts were drafted this year. Nine contracts were executed within the

grant year and will carry into the 2018-2019 fiscal year; three contracts are scheduled for

execution next fiscal year (see Graph 1). Six planning and disparity agreements were executed

which span both fiscal years. Two HPV vaccination sites were identified for funding through

competitive solicitation, one was assessed this fiscal year and one will be assessed in fiscal year

2018-2019. Both will implement systems change work in year two. Two community-clinical

6 Community Preventive Services Task Force. Recommendation for use of immunization information systems to increase vaccination rates. Journal of Public Health Management & Practice. 2015;21(3):249-252. Available at: http://journals.lww.com/jphmp/Fulltext/2015/05000/Recommendation_for_Use_of_Immunization_Information.3.aspx.

7 Groom H, Hopkins DP, Pabst LJ, et al. Immunization information systems to increase vaccination rates: a Community Guide systematic review. Journal of Public Health Management & Practice. 2015;21(3):227-248. Available at: http://journals.lww.com/jphmp/Fulltext/2015/05000/Immunization_Information_Systems_to_Increase.2.aspx.

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linkage sites were identified for funding through competitive solicitation and began work this year

and will run through fiscal year 2018-2019. An additional agreement was drafted for evaluating

these intervention sites. Given the complexity of the systems change work within HPV

vaccination, additional dollars were allocated to assessing and providing feedback to the first HPV

vaccination system prior to conducting the systems change practices.

Graph 1: Program Contracts to Address Comprehensive Cancer Strategies, 2017-2019 (n=12)

Cancer planning and disparity contracts provide seed funding for the development of

regional cancer control strategic plans and the training of health care professionals on cancer

disparity data and CDC recommended cultural competencies. Intervention impacts and details on

these intervention sites are explored further under question 9.

Cancer prevention contracts fund improvement projects within individual health care

systems to increase HPV vaccination initiation and completion rates for children between 11 and

15 years old. Interventions provide support for implementing three evidence-based practices for

improving HPV vaccination rates: provider assessment and feedback, provider reminder systems,

and patient reminder systems. Contracts for two systems, Family Health Centers of Southwest

Florida and Langley Health Services, were drafted during this reporting period for execution in

fiscal year 2018-2019. Intervention impacts and details on these intervention sites are explored

further under question 7.

Access to cancer care contracts fund community-clinical linkage intervention projects to

increase cancer screening demand and survivor support service demand. Proposals were funded

based on their ability to enhance current and potential collaborations between partner health

systems: how do cancer partners within these regions currently interface; how do they prioritize

patient support for services outside of their current system? Two systems, the Pasco County

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Planning andDisparities

Prevention: HPVVaccinationAssessment

Prevention:HPV VaccinationSystems Change

Access to Care andSurivorship:

Community-ClinicalLinkages

Evaluation

Contractual Agreements by Fiscal Year, 2017-2019

FY 17-18 FY 18-19

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Referral Network and the Volusia County Referral Network, were funded to solidify and formalize

their referral process. Project sites will be funded and evaluated over a 18-month period. By the

end of the reporting period, there were 31 partner agreements executed across six counties which

formalize the referral process and data sharing for evaluation and process improvement needs.

Additional intervention sites will be selected next fiscal year for funding around July 2019.

Intervention impacts and details on increasing access to cancer screenings and survivor support

services are explored further under question 6 and 8, respectively.

3. Have EBIs maintained the fidelity of the regional strategic plans (i.e., delivered as it

was intended)?

Prior to releasing funding opportunities to support regional strategic plans, literature

reviews of evidence-based practices were conducted to define the parameters for the funding

announcement and contractual agreement. The Community Guide Task Force recommendations

and the Library of Indicator Data Source were used to determine adherence to EBI and best

practices for strategies selected.

A literature review revealed gaps in knowledge around systems change work to increase

HPV vaccination. In general, vaccination rates have been improved through systems change work

using Immunization Information Systems (IIS) including provider reminders, patient reminders,

and provider assessment and feedback.8 Study data on IIS has focused on vaccinations required

by school systems. Investigation of IIS practices to increase HPV vaccination, a recommended

vaccination, could identify how effective system change work is on increasing rates particular to

this vaccination as well as illuminate if potential differences exist between the impacts of systems

change on required versus recommended vaccines. There is limited evidence to evaluate the use

of IIS by vaccination providers in clinical settings despite the potential use within these systems.9

Assessing effectiveness of system change work would benefit funders and institutions who have

an interest in addressing sexually transmitted infections and cancers caused by HPV. In addition,

other factors which influence implementation of practices such as clinic characteristics and

patient demographics could be assessed for effect modification. A research proposal was

developed to improve the scientific knowledge around this intervention and will be ongoing

throughout the implementation at project sites.

8 Community Preventive Services Task Force. Recommendation for use of immunization information systems to increase vaccination rates. Journal of Public Health Management & Practice. 2015;21(3):249-252. Available at: http://journals.lww.com/jphmp/Fulltext/2015/05000/Recommendation_for_Use_of_Immunization_Information.3.aspx. 9 Groom H, Hopkins DP, Pabst LJ, et al. Immunization information systems to increase vaccination rates: a Community Guide systematic review. Journal of Public Health Management & Practice. 2015;21(3):227-248. Available at: http://journals.lww.com/jphmp/Fulltext/2015/05000/Immunization_Information_Systems_to_Increase.2.aspx.

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4. How have cancer plan objectives increased regional support for cancer activities?

CCCP has incorporated policy, systems, and environmental change (PSE) approaches into

its overall strategic foundation. PSE approaches have allowed past member projects and regional

activities to outlast funding and support, becoming fixtures among regional collaboratives and

testaments to the importance of coordination among partners.

An example of a long-standing project is the giant colon patient outreach in South

Florida. Each year since 2015 regional collaborative partner sites host awareness events using the

giant inflatable colon to draw in health system patients and refer or sign patients up for colorectal

cancer screenings. In 2017-2018, six-member sites hosted colorectal cancer screening awareness

days during national awareness month in March. Past regional planning efforts to increase

patient and provider education on HPV vaccination continues as well. Two regions still prioritize

support for and/or directly host screenings of a documentary on HPV vaccination, Someone You

Love, to promote the vaccination and work to increase adoption and recommendation of the

vaccination.

Prior PSE grant efforts highlighted the need for health systems change work on HPV best

practices. This year that systems change work will continue and expand to address inter-systems

change work through community-clinical linkages. Community-clinical linkages efforts this year

modify how systems coordinate to address cancer screening and cancer survivor support service

referral. Participating partner health system reviewed and revise their policies to outline how

patients and clients will be identified and referred throughout a multi-partner network.

Opportunities for participating in PSE efforts are tied to regional collaborative plans and partners’

activities are evaluated to determine impact on increasing cancer prevention, cancer screening

referrals, and survivor support referrals.

5. How were cancer data used to plan and guide FCCCP efforts statewide?

Program staff used Florida cancer data, program data, and research data to construct new

mapping systems and determine priority regions for addressing low cancer screenings such as

colorectal, regional collaborative impact and sustainability, and communicating health disparity

data to the health professionals to empower workforce action through best-practices in cultural

competency.

Priority regions for cancer screening interventions were constructed through a collaboration

between the Florida Cancer Data System (FCDS) and FCCCP. FCDS provided ten-year cancer

trend data on late stage cancer incidence and cancer mortality. Regional stakeholder groups were

provided national trends in cancer disparities and cultural competency best practices

recommended by the CDC.

To better guide collaborative members and leadership, a crosswalk between the Florida

Cancer Plans and collaborative efforts was constructed. A team of internal cancer stakeholders

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compiled the crosswalk and analysis through an external evaluation team is planned for fiscal

year 2018-2019. Data was also collected, tracked, and measured the growth and success of the six

regional cancer collaboratives against publicly available national and state level standards.

6. How has cancer screening awareness and education increased over the past year?

FCCCP worked with the FDOH Breast and Cervical Cancer Early Detection Program and

Colorectal Cancer Control Program to enhance cancer screening awareness, promotion and

prevention activities.

As outlined in the action plan, FCCCP competitively solicited funding for breast, cervical, and

colorectal cancer screening support through the collaborative action. Two intervention sites were

awarded, one in Pasco County and another in Volusia County, which combined reached 31

partner health systems. Patient baselines are currently being established for cancer screening

referral by cancer site and cancer survivor support referral by physical activity and other support

services. Based on the six-county reach and size of the systems, the interventions are expected to

reach a broad, diverse range of clients and patients to address both perceived barriers to care

regardless of insurance status.

The partner make-up of the referral networks is also diverse. Each referral systems engages

Federally Qualified Health Centers and free and charitable clinics to reach patients that may have

screening or treatment challenges. Large institutions are also involved and have programs to

support patients who feel they may have barriers to care.

In collaboration with the American Cancer Society, two Cancer Free Webinar series were

planned for July 2018 and September 2018. Continuing medical education (CME) and continuing

education unit (CEU) will be provided and is expected to reach an average of 100 health

professionals. Feedback on future topics will be collected and evaluated during the trainings to

guide future webinar topics.

7. How has cancer prevention activities increased over the past year?

A funding opportunity was released through a request for application for a HPV vaccination

system change to increase the vaccination rates of children between the ages 11-15. Providers were

awarded in February 2018 with a second award in June 2018. Two contracts have been developed

for execution in fiscal 2018-2019. The HPV vaccination system change project sites are Family

Health Centers of Southwest Florida, with an executed contract containing nine pediatric clinics,

and Langley Health Services, with a draft contract set for execution in October 2018.

Family Health Centers will update their policies and procedures, training their staff,

educating the patients and their families about the vaccine through patient reminders, and

enhancing patient record systems to allow generation of provider reminders for eligible patients.

The provider’s proposal following the request for application states that the compliance rate was

at 27.8% as of December 2017. The University of Central Florida (UCF) performed an audit of the

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patient charts and electronic medical records as an independent contractor. Following a chart

audit of 10% of the patient population, Family Health Centers was found to be performing at a

compliance rate of 82.76%. According to UCF’s evaluation, the pediatric clients with Family

Health Centers of Southwest Florida are almost split evenly between male and female, but 57% is

Hispanic, 42% is Non-Hispanic, with 1% of unknown ethnicity. The Hispanic ethnicity has the

highest HPV immunization rates at 88%. Medicaid is the primary insurance coverage among the

populations served at these pediatric clinics. The provider has been requested to review their files

and verify the correct amount.

The second HPV vaccine system change project is a result of a block grant opportunity with

the Bureau of Chronic Disease Prevention with the Project Health, Inc. doing business as Langley

Health Services. Langley Health Services approach to increasing the HPV vaccination rate among

11-15-year-olds is not only to update the policies and procedures, but also to allow for greater

access to HPV vaccinations. Langley will be using a mobile medical unit and a mobile dental unit

for HPV vaccinations as well as having Saturday clinics and vaccine only appointments available.

Per the proposal submitted by Langley Health Services, out of the 22.4% of patients that started

the HPV vaccination series, only 15.3% of the patients finished the vaccination series. The

provider’s goal is to increase the HPV vaccine completion rates by 10%.

8. How has cancer survivor support increased over the past year?

Internal and external partners worked to develop infrastructure and measures for

increasing cancer survivor support services. An area of high need remains with connecting

patients and clients to these services, so processes for improving community-clinical linkages

were developed address this gap. Improvements were made based on the overall care delivery

systems and focus on more efficient care delivery through connectivity with external systems.

Interventions conducted this fiscal year focused on increasing measures of physical activity

support of cancer survivors, which has been shown to reduce morbidity and mortality for cancer

of the breast, colon, rectum, and prostate.

Both referral networks established during this reporting period have partnered with

community and clinical organizations that provide cancer survivor support services. Services

included in each referral system address access to physical activity and mental health. Programs

like the LiveSTRONG in YMCAs in both referral systems have welcomed referrals for survivors to

gain access to free 12-week courses for physical activity support. In addition, cancer survivor

support groups have been opened or extended at some facilities to accommodate mental health

needs for patients that may not be aware of these services. More information on the referral

networks can be found in the response to question six.

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9. How have cancer disparities decreased over the past year?

Six cultural competency and disparity trainings were held in each region of the state

between April and June 2018. This resulted in 110 health care providers receiving education on

cancer disparities within the state and specific to their region as well as training on cultural

competency to address these disparities. Each regional cancer control collaborative received

support from the Office of Minority Health at the Department of Health, including training notes

on cultural competencies and help finding or providing a speaker for the trainings.

Attendees were reached statewide with professions ranged from medical anthropologists,

nurses, mental health workers, and social workers. Attendees received an average of two hours of

training and summed to 226 total training hours provided. Cancer disparity data was presented in

a variety of methods with the statewide data analysis systems providing the information. Cancer

data presented reflected national standards for known disparities, stemming directly from reports

published by the National Cancer Institute.

Attendees were evaluated for baseline measures within four cultural competencies

recommended by the Culturally and Linguistically Appropriate Services in Health and Health

Care Policy and Practice and four cultural competencies recommended by the National Center for

Cultural Competency and the Georgetown University Center for Child and Human Development.

Attendees received a call to action at the end of the training to continue collaboration and

coordination through regional communities of practice and included materials for continued

education and self-learning. A six to twelve month follow-up period will be used to determine the

impact of training and change of clinical practice.

10. What methods were used to improve planning coordination between statewide

external partnerships and internal stakeholders?

External and internal stakeholder coordination were addressed through standalone and

ongoing networking trainings between regional coordinators, regional steering groups, statewide

partnership, and FCCCP staff.

Ongoing meetings helped facilitate open and consistent communication across the state.

Monthly meetings were held between regional collaborative coordinators and FCCCP staff. The

meetings facilitated technical assistance between regions and included state and regional updates

as standing agenda topics. Select meeting topics included extracting cancer data from public

sources, regional strategic plan overview, sharing of best practices, innovative strategies for

implementing projects without funding, and process improvement strategies. Coordinators report

these meetings between colleagues and FCCCP staff as beneficial to their work. In-person regional

planning meetings where held at least twice a year in each area across the state and were attended

by both local- and state- level stakeholders.

Ad hoc groups and communities of practices were formed to address specific topics on a

regional and state level, including regional planning committees, grant committees for regional

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and state grants, and intervention specific committees to address challenges and opportunities

identified during implementation of project work plans.

Barriers to Cancer Control

Cancer control planning efforts were limited by funding constraints. The FCCCP entered a new

grant cycle and was tasked with further diversifying the same funding into at least four intervention areas.

As a result, funding to support planning efforts were cut in half to allow more resources to support

implementation of interventions. Planning requirements of funded agencies were thereby reduced and

additional dollars for a disparity intervention were integrated into planning efforts to have a stronger

focus on stakeholder engagement on areas of highest opportunity and need.

In addition, the FCCCP had a vacant coordinating staff position from July 2017 to February 2018.

During the interim period, the Program Director continued to conduct monthly meetings with cancer

planning agencies and managed the other administrative responsibilities such as development of

intervention solicitations and development of new agency agreements to conduct EBIs.

The process for funding announcements through a request for application was a major barrier in

beginning the HPV Vaccine System Change project along with the contract drafting process. The

community clinical linkages systems have provided feedback stating the lack of preparation time needed

to get the referral network systems built and running was a major constraint to the project.

Lessons Learned

This period focused on redevelopment of strategic plans through specific, actionable strategies

toward preventable cancers and creation of funding opportunity announcements to identify and support

implementation of regional strategies and objectives. Future efforts will seek to address progress made,

barriers to overcome and overall impact of the grant. Continuous growth in membership, completion of

many of the original 2017-2018 strategic plan objectives, and new national opportunities emphasize the

need for new systems and processes for measuring and directing impact.